Patient with a past medical history of thyroid lymphoma in 2010. It is unclear from records whether his dermatologists knew this.
He also had known past excisions of basal cell carcinoma and squamous cell carcinoma.
- 5/17/2021: Patient went to his regular dermatologist, Dr. K., complaining of an “insect bite” on his face, present 6-7 weeks. Dr. K.’s records describe a “pink crusty plaque” in the right pre-auricular area, and states: “Clinically, this looks like a large squamous or basal cell carcinoma. I discussed this with him in detail. A feature that goes against this being a skin cancer is the fact that it occurred overnight. He also says that it has minimal itching and has fluctuated in size. He is convinced it is a brown recluse spider bite, although there are no areas of necrosis present. It [has] been present for 6 weeks and I told him normal protocol is to biopsy lesions that persist for 4-6 weeks. He declined a biopsy at this time and said he[‘d] rather try a topical antibiotic. He promised that if it did not go away he would allow me to biopsy it. I explained to him that if it is a skin cancer would be quite large and the sooner we determine this the better.”
- 6/21/2021: follow-up Dr. K.. Patient reported having used Mupirocin for 2 weeks, and that the lesion became “angry.” Dr. K. did punch and shave biopsies and noted: “Once again, I told him that I thought this was either a basal or squamous cell carcinoma. His history is suggestive of a keratoacanthoma. It is very large for any type of skin cancer and came up quite rapidly. I once again told him that this might be malignant. He understands that it may need additional treatment. I told him that large SCC can behave very aggressively and the faster that we get this diagnosed and treated the better he will be.”
- 6/25/2021: Punch and shave biopsy results: well-differentiated SCC. Dr. K. notified patient and sent a referral for a dermatologist specializing in Mohs surgery.
- 6/28/2021: Follow-up with Dr. K. for suture removal. Dr. K. documented: “I discussed with him how extremely important it is to get this large SCC on his face taken care of as soon as possible. I told him that some SCC could metastasize and if it did it could kill him. I was uncomfortable with our conversation because he kept asking me for alternatives to therapy. I told him I could send him to M.D. Anderson or Mayo Clinic or a plastic surgeon but he continued to perseverate on how he did not want to have anything done unless needed to be done. When I tried to explain to him that we needed to get the input from surgeons, he kept going back to the idea that he did not want treatment if he didn’t need it. I assured him that skin cancer this large had the potential to be very problematic. I tried to discuss the concept of a large keratoacanthoma but I do not believe he grasped what I was saying. That made it even more important for him to see somebody as quickly as possible. I think the Mayo Clinic is ideal and we made a referral….”
- 7/1/2021: 1st visit to Mohs specialist Dr. M. (not at Mayo Clinic, but also recommended by Dr. K.). At the time of this appointment, Dr. M. appears to have had Dr. K’s notes from May and June, which had been faxed to Dr. M. on 6/28/21 along with the biopsy pathology report. The chief complaint for the appointment was “squamous cell carcinoma.” Patient reported that the lesion “has gotten significantly smaller than it was initially and even feels that it has continued to get smaller since it was biopsied. He also notes that Dr. K. mentioned that it may be a kind of tumor that goes away on its own, but that his siblings were very concerned and wanted him to take it more seriously.” Dr. M.’s records reflect that the lesion was 3.5 cm x 3.2 cm, with a MAUC score of 9. Dr. M. reviewed “the various treatment options for skin cancer removal” with the patient, but agreed that “given the history of recent regression and the initial appearance described by the patient, … this tumor may very well be a regressing keratoacanthoma, which could end up disappearing spontaneously, without any further intervention.” Dr. M. told him that “if we waited a few weeks, and the tumor continued to resolve on its own… we may feel much better about not moving forward with surgery.” Together, they decided to wait 4 weeks and reassess.
- 7/29/2021: Follow-up visit to Dr. M., who described a “large resolving, eroded plaque on R cheek with loose, keratinaceous debris” and “no underlying induration noted.” He noted, “The wound is healing within normal limits.” Dr. M. manually debrided the lesion of keratin with “CTAs” and added, “Tumor is reducing in size significantly.” A photograph taken with a ruler that day appears to show that the lesion was around 4 cm long. Dr. M. instructed the patient to follow up in another month.
- 8/26/2021: Follow-up with Dr. M. Notes describe “residual keratotic plaque with central clearance, consistent with resolving KA,” with a plan of observation and follow-up in 1 month.
- 9/23/2021: Follow-up with Dr. M. Notes state: “Exam reveals total central clearing of the tumor, with some residual active border – consistent with keratoacanthoma centrifugum marginatum.” Dr. M. did a curettage of the lesion, and the size before and after was noted to be 4.2 cm x 3 cm.
- 10/19/2021: Follow-up with Dr. M. Notes state: “areas of debridement from last month have resolved beautifully. Still 2 stubborn areas that are palpable and suggestive of proliferative zones.” They discussed options of “intralesional 5FU vs observation,” and the patient chose to proceed with 5FU injection.
- 11/15/2021: Follow-up with Dr. M. Notes state: “site is centrally flat and cleared with 2 areas that appear slightly raise[d] and likely represent proliferative areas.” Dr. M. recommended 5FU injections to these “two small papules,” but the patient wanted to wait and see if they improved on their own. Dr. M. instructed him to follow up in 2 more months.
- 1/21/2022: Follow-up with Dr. M. Notes state: “his growth, unfortunately, has epithelialized and started to grow again.” Dr. M. recommended another 5FU injection, and starting low-dose soriatane, and the patient agreed. Dr. M. ordered “baseline labs” to be done. The size of the lesion was noted to be 4.6 cm x 3.5 cm.
- 2/24/2022: Follow-up with Dr. M. Notes state: “[Patient] has noted rapid growth in the last 2 weeks, but some improvement in the last couple of days. Areas that were injected have improved but areas that weren’t seem to have grown. Labs came back normal and we were planning on starting soriatane and discussing this route.” Dr. M. further described “rapid growth of areas just anterior to the tragus. This area has become tender in the last 2 weeks.” The lesion was noted to be 4.8 cm x 4.3 cm. Dr. M. and the patient decided to proceed with Mohs surgery.
- 2/28/2022: Dr. M. did Mohs surgery but after multiple passes was unable to clear the tumor, now measuring 5 cm x 4 cm. His notes state: “A focus of perineural invasion was noted between the posterior parotid gland and anterior border of tragal cartilage. … All other margins were clear.” The final surgical defect measured 7 cm x 6.5 cm, and it could not be closed primarily. Dr. M. referred the patient to MD Anderson cancer center for “further surgical management and possible adjuvant XRT.”
- 3/18/2022: Patient underwent right parotidectomy with facial nerve preservation, right selective neck dissection and wide local excision right check, followed by cervicofacial advancement flap for closure of right facial defect, at MD Anderson.
- “Pathology returned with small focus of tumor with perineural invasion. Stage T3N0.” Pathology report is attached. The patient did well post-op and followed up as instructed, with the exception that he postponed a scheduled restaging scan from June to August of 2022 due to travel. After discussion with his oncologists, patient initially chose not to proceed with radiation therapy in a previously irradiated field, especially when the records from his radiation treatments in 2010 could not be found.
- 8/3/2022: CT scan with IV contrast was done as part of a restaging evaluation. The report described “a small amount of subcutaneous intermediate density near the superior edge of the surgical cavity measuring approximately 1.5 cm in AP dimension.” Under “impression,” the radiologist wrote: “On coronal reformats this density appears linear and is favored granulation tissue/scar but warrants attention at follow-up to exclude possible tumor.” one linear area of possible concern measuring 1.5 cm. On physical exam, the oncologist noted, “No evidence of concerning nodularity correlating to CT neck linear scar tissue.”
- We do not have all records yet, but the patient’s cancer was found to have spread. On 12/22/2022, he underwent another neck dissection, with 2 out of 9 lymph nodes positive for metastatic squamous cell carcinoma. The largest tumor deposit found measured 0.9 cm, and the pathology report described “extensive extranodal extension (>2 mm), along with the presence of perineural invasion and a focally positive margin of resection. The patient is currently undergoing chemotherapy and radiation treatments.
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Do you believe there might have been medical error?
A 3.6 x 3.2cm SCC that is biopsy proven and documented in the medical record does not 'resolve on its own' and not treating it surgically and expeditiously is very likely malpractice. The following visits with Dr. M only reinforce the level of poor decision making and breach of duty by him or her. 5-FU is a reasonable treatment option but given the documented size of the tumor and the multiple failures of the tumor to involute or resolve that should not have been given as an option. In addition "observation" and "soriatane" are not reasonable therapeutic options to present to a patient who very likely needed to be educated on how dangerous his tumor was (which Dr. K seems to have done quite well). Once Mohs finally was done, leaving positive margins with perineural invasion is never the goal of Mohs surgery. It is occasionally necessary to abort a case with positive margins but these should be exceedingly rare.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Please see above. The inadequate treatment offered before Mohs likely led to a delay in definitive surgical treatment which is the standard of care for this lesion.
What makes you a good expert for this case?
I practice Mohs surgery all day every day. I have treated over 10,000 skin cancers and I am a credible, articulate expert in this exact field.
How often do you encounter cases similar to this one in your practice?
I treat SCC daily and encounter dangerous lesions with metastatic potential several times per month.
Do you believe there might have been medical error?
The Mohs surgeon was within the standard of care to try non-surgical measures for perhaps one attempt. Given the size and persistence of this squamous cell carcinoma, he had an obligation to stop acquiescing to the patient's desire for non-surgical and clearly tell the patient that the patient's only options were Mohs surgery, excision under IV sedation or general anesthesia with frozen section assessment, or radiation therapy. To continue to try non-surgical options was below the standard of care, with profoundly negative results. This is especially so, since the tumor was greater than 2.0 cm in diameter - placing the tumor in the high-risk category for deep invasion and local metastasis. Although keratoacanthomas can rarely regress, evidence of regression occurs relatively soon after onset. Continued persistence of the patient's tumor, even with partial resolution with the non-surgical measures should have strongly suggested to the Mohs surgeon that this tumor was an squamous cell carcinoma
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The extensive tumor invasion of the squamous cell carcinoma when finally excised is a direct result of the delay in standard-of-care treatment - excision or radiation therapy
What makes you a good expert for this case?
I am a fellowship trained Mohs surgeon, have performed over 30,000 Mohs surgery cases, and have expertise in managing complications associated with Mohs surgery. I have testified in court for a Defendant in a delay in diagnosis case of squamous cell carcinoma and will be testifying in court for a Plaintiff in a similar case this month. I have co-edited two textbooks on Mohs surgery, written 13 textbook chapters and published 45 scientific papers in journals, most on dermatologic surgery issues. I also co-created and co-directed their annual Fundamentals of Mohs Surgery Course for 25 years. I have taught residents Mohs surgery and dermatologic surgery for over 32 years as an assistant professor at the University of California, San Diego and as an Associate Professor and Director of Mohs and Dermatologic Surgery at Texas A&M School of Medicine. I currently am an associate professor of surgery at Campbell University School of Medicine.
How often do you encounter cases similar to this one in your practice?
I have encountered thousands of cases of facial squamous cell carcinoma and keratoacanthoma, including a great many that were large facial lesions. In nearly all cases, it was the referring dermatologist who would have attempted non-surgical measures before the patient was sent to me.
Do you believe there might have been medical error?
This patient had a large KA, which is a variant of an SCC. KA's have a complex history in the literature. Historically, many physicians would observe these as they do have the potential to spontaneously involute. However, in general, this approach is less favored by most in the community as they also have the potential to metastasize. Most dermatological surgeons would not observe a cancer like this - however, it is my guess that this patient was leading the management based upon his prior resistance to surgical options.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
A delay in definitive treatment could have resulted in the deeper and peri-neural involvement of this aggressive KA. However, it should be noted that this cancer was large and aggressive at the time of diagnosis, and it would be impossible to tell definitively if the perineural involvement already existed at the time of diagnosis.
What makes you a good expert for this case?
I have extensive experience with KA, SCC, etc, and am a board certified Mohs surgeon
How often do you encounter cases similar to this one in your practice?
Often... though we would not have observed the cancer. We would have excised it with Mohs, or discharged the patient from our practice.
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